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Chapter 2 Introduction to Health Records
Medical Terminology (HEAL 1800)
University of Toledo
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Medical Terminology 11 September 2017 Chapter 2: Intro to Health Records The SOAP Method: Subjective: ❖ The first part of the note is the subjective part. It is subject to how a patient experiences and personally describes his or her problem as well as personal and family medical histories. Put simply, it is the problem in the patient's own words. The subjective data includes the duration of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem. ➢ These are the problems that the patient states/he she has. “I feel like…” ➢ Those problems are then translated into medical terms. ■ This is so that you can correctly communicate the problems to all health care providers ❖ General Subjective Terms: ➢ Symptom ➢ Noncontributory ➢ Acute (less than three months) vs. Chronic (more than three months) ➢ Abrupt ➢ Progressive V. Exacerbation (Remission) ➢ Febrile (Fever) vs. Afebrile (Without Fever “a”) Objective: ❖ The next step in the investigative process includes collecting objective data. Objective data comprise the patient's physical exam, any laboratory findings, and imaging studies performed at the visit. Can physically see, hear, and smell these symptoms. ❖ General Objective Terms: ➢ Things that are seen: alert (conscious or unconscious) , oriented (can be conscious, but they are able to tell you their name, date, can count, etc) ➢ Things that are felt: palpation (lightly touching them from head to toe, feel any abnormalities) ➢ Things that are heard: Auscultation (take stethoscope, listen to heart, bowel/digestive sounds), percussion (cup hand, place over abdominal region, listen for sounds of dullness or fullness (Empty or full bowels) ➢ Descriptions of what is observed: Unremarkable (no differences from the other side), marked (different compared to the other side, ex. Right leg is sprained) Assessment: ❖ Upon gathering all the pertinent information, the healthcare provider formulate a logical analysis this is known as the assessment. An assessment could be a diagnosis, and identification of a problem, or a list of possibilities for the diagnosis which is known as a differential diagnosis. ❖ General Objective Terms: ➢ Impression: What you think it’s wrong ➢ Diagnosis: What is actually wrong ➢ Differential Diagnosis: Almost positive you know what’s wrong, but not ready to make diagnosis just yet. ➢ Etiology (cause of the disease) vs. Idiopathic (No known cause) ➢ Benign (not cancerous) vs. Malignant (cancerous) ➢ Remission: No longer showing symptoms, but still have the disease. ➢ Morbidity: Risk of being sick or diseased. ➢ Mortality: Risk for dying. ➢ Prognosis: Chance of getting better/what’s going to happen next. ➢ Localized (one area) vs. systemic/generalized (Over a large area or body system) ➢ Pathogen: Organism that causes the disease. ➢ Lesion: Diseased tissue ➢ Sequelae: Result of disease or injury; for example, paralysis can be the sequelae of spinal cord injury. General Plan: ❖ The provider then formulates a plan or a course of action consistent with his or her assessment. The plan could be a treatment with medicine or procedure. It could also consist of collecting for their dated help arrive at a more accurate diagnosis. ❖ General Plan Terms: ➢ Disposition: Where they are going after they receive treatments ➢ Observation: Observe the patient, see if there is any changes ➢ Reassurance: Try to offer this to the patient to keep them calm, or if they don’t understand you can explain it. ➢ Supportive Care: Something that you do to help the patient feel better. ➢ Palliative: Helping the patient feel better, but the prognosis is grim. Like Hospice. ❖ The process of collecting subject of history, gathering objective data, formulating an assessment, and developing an action plan is if he didn't every healthcare visit across all disciplines of medicine. It is a baseline of thought and medicine. Consequently, healthcare records reflect this thought process. ❖ Upon admittance to the hospital, patients must provide a medical history and receive a physical exam. Afterward, the attending medical professional writes a detailed admission summary. Detailed admission summaries are usually thorough notes that are very heavy Areas of the Health Care Facility: ❖ Pre-Op: Where the family members wish the patient good luck and it's before they enter the OR. ❖ OR: Operating Room, where the surgery takes place ❖ PACU: Post Anesthetic Room ❖ Post-Op: After anesthesia ❖ ICU: Intensive Care Unit: CCU (Critical Care Unit-NOT ON THE TEST), SICU (Surgical Intensive Care Unit), PICU (Pediatric Intensive Care Unit), NICU (Neonatal Intensive Care Unit) ❖ ER: Emergency Room ❖ ED: Emergency Depart ❖ ECU: Emergency Care Unit ❖ L&D: Labor and Delivery Common on Health Records: ❖ VS (vital signs) are made up of the HR (HEART RATE), RR (RESPIRATORY RATE), BP (BLOOD PRESSURE), and T (TEMPERATURE). ❖ I/O: Input/Output ❖ Dx: Diagnosis ❖ DDx: Differential Diagnosis ❖ Tx: Treatment ❖ Rx: Prescription ❖ Hx (History): PMHx (Past Medical History; FHx (Family History)) ❖ H&P: History and Physical ❖ CC: Chief Complaint ❖ HPI: History of Present Illness ❖ ROS: Review of Systems ❖ PE: Physical Exam ❖ PCP: Primary Care Provider/Physician ❖ Prn: As needed ❖ QID: Four times daily ❖ QD: Daily ❖ AC: Before meals ❖ TID: Three Times Daily ❖ BID: Two Times Daily ❖ PC: After meals ❖ QHS: At night Types of Health Records: Sections of a Description Health Record Chief complaint The main reason for the patient's visit History of The story of the patient's problem present illness Review of systems Past medical history Past surgical Description of individual body systems in order to discover any symptoms not directly related to the main problem Other significant past illnesses, like high blood pressure, asthma, or diabetes Any of the patient's past surgeries history Family history Any significant illnesses that run in the patient's family Social history A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health ❖ Upon admittance to the hospital, patients must provide a medical history and receive a physical exam. Afterward, the attending medical professional writes a detailed admission summary. Detailed admission summaries are usually thorough notes that are very heavy on the subjective and objective parts, because the idea of the summary is to assemble all the facts in one place to help direct the entire hospital course. ❖ The assessment, which usually describes the thought process behind a patient's diagnosis and a list of possible causes for the patient's problem, is known as a differential diagnosis. Common Terms on Health Records: ❖ general subjective terms Term acute ah-KYOOT Definition it just started recently or is a sharp, severe symptom Term alert Definition able to answer questions; responsive; interactive ah-LERT oriented being aware of who he or she is, where he or she is, and the current time; a OR-ee-EN-ted patient who is aware of all three is “oriented × 3” marked it really stands out MARKT unremarkabl another way of saying normal e un-ree-MARKah-bul auscultation to listen aws-kul-TAYshun percussion to hit something and listen to the resulting sound or feel for the resulting per-KUH-shun vibration; drums are a percussion instrument palpation to feel pal-PAY-shun general assessment terms Term impression Definition another way of saying assessment im-PREH-shun diagnosis DAI-ag-NOH-sis what the health care professional thinks the patient has differential a list of conditions the patient may have based on the symptoms diagnosis exhibited and the results of the exam dih-fer-EN-shal DAI-ag-NOH-sis benign safe beh-NAIN malignant dangerous; a problem mah-LIG-nant degeneration to be getting worse dee-jin-er-AY-shun etiology the cause ee-tee-AW-loh-jee remission reh-MIH-shun idiopathic to get better or improve; most often used when discussing cancer; remission does not mean cure no known specific cause; it just happens ih-dee-oh-PA-thik localized LOH-kah-LAIZD stays in a certain part of the body seh-KWEL-ah pending waiting for PEN-ding general plan terms Term disposition Definition what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, dis-poh-ZIH- normal hospital bed) shun discharge literally, to unload; it has two meanings: DIS-charj 1. to send home (to unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (your body unloading a fluid) prophylaxis preventive treatment PROH-fuh-L AK-sis palliative treating the symptoms, but not actually getting rid of the cause PA-lee-ah-ti v observation watch, keep an eye on OB-zer-VAY -shun reassuranc to tell the patient that the problem is not serious or dangerous e ree-ah-SHU R-ants supportive to treat the symptoms and make the patient feel better care suh-POR-tiv kehr sterile extremely clean, germ-free conditions; especially important during medical procedures and surgery STEH-ril opposites Term proximal PRAWK-sih-mal distal DIH-stal Definition closer in to the center proximal and approximate come from the same word and mean close farther away from the center distal and distant come from the same word and mean far dorsal/posterior the back DOR-sal/ a dorsal fin on a shark is on its back pohs-TEER-ee-or cranial toward the top KRAY-nee-al caudal toward the bottom KOW-dal from Latin, for tail superior above soo-PIH-ree-or inferior below in-FIH-ree-or prone lying down on belly PROHN supine lying down on back SOO-pain contralateral KON-trah-LA-ter-al opposite side dorsum the top of the hand or foot DOR-sum plantar the sole of the foot PLAN-tar palmar PAL-mar the palm of the hand Body Planes Another way of looking at the body is through the three dimensions: right to left (sagittal), front to back (coronal), and top to bottom (transverse). This is especially important in radiology. For instance, a CT scan is actually a series of layered images along one of these dimensions. body planes Term Definition sagittal divides the body in slices right to left SA-jih-tal sagitta is Latin for arrow; think of this as dividing the body in half, as if someone shot an arrow through it. coronal divides the body into slices from front to back kah-ROH- corona is Latin for crown; this plane divides the body in half from the top of the nal transvers e head down divides the body from top to bottom Abbreviatio Definition n CCU coronary care unit ECU emergency care unit ER emergency room ED emergency department ICU intensive care unit PICU pediatric intensive care unit NICU neonatal intensive care unit SICU surgical intensive care unit PACU postanesthesia care unit L&D labor and delivery OR operating room post-op after surgery pre-op before surgery
Chapter 2 Introduction to Health Records
Course: Medical Terminology (HEAL 1800)
University: University of Toledo
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